An RWJF Collection

Kinder, Gentler Reform Needed to Avoid Physician/Patient Divide

March 21, 2013

As the nation rushes to create a leaner, more cost-effective health care system, even the most attentive physicians may lose sight of their patients’ most pressing concerns, said Robert Wood Johnson Foundation (RWJF), U. S. Department of Veterans Affairs Clinical Scholar (2012-2014), Lisa Rosenbaum, MD.

Rosenbaum, a cardiologist, has become increasingly aware of the gap between what patients want and what the health care system may provide. “When we speak of the value [of a medical treatment or test], we must realize that patients may value procedures that health care experts consider a waste of resources,” she said.

She recently wrote two essays that analyze the disconnect between evidence-based health reform recommendations and the personal needs and desires of patients. They were “The Whole Ball Game: Overcoming the Blind Spots in Health Care Reform,” published in the March 7 New England Journal of Medicine(NEJM) and “Digitizing the Doctor-Patient Relationship,” written for the 2013 Academy Health National Health Policy Conference.

Rosenbaum fears that the swift embrace of Affordable Care Act recommendations will lead to cost trimming and technology use that may alienate patients and reduce the quality of care.

Looking Beyond the Evidence

To illustrate her point, she shares the case of a patient who came to her paralyzed with anxiety because he thought he would suffer a heart attack like his father. He had taken some tests and was greatly in need of lifestyle modification, but he asked Rosenbaum, “isn’t there some other test that you could do?”

The patient was asking for cardiac imaging. A test the Medicare Payment Advisory Commission has identified (along with other imaging tests) as a leading and often unnecessary contributor to rising health care costs. “With [imaging test] volume per beneficiary growing at twice the rate of other physician services… it appeared that cardiologists were self-referring, so reimbursement for outpatient cardiac imaging was cut by as much as 40 percent, while ordering of the tests was strictly monitored,” Rosenbaum explained in NEJM. As a result, she did not comply with her patient’s request.

“Yet, there is something very powerful about that imaging test in some cases,” Rosenbaum said, citing research showing that patients are more satisfied with care when imaging is performed.

To quell the patient’s anxiety, Rosenbaum referred him to the cardiologist supervising her work. The physician spent 75 minutes with him, carefully explaining why all of the heart disease tests he found online might not stop a heart attack and recommending lifestyle modifications.

“The patient was greatly relieved,” Rosenbaum said. “He explained that no physician had ever spent that amount of time with him before.” The point, she added, is that the “evidence” showing that the imaging test would not prevent a heart attack—or was without value—did nothing to calm her patient. For him, the test was additional reassurance that everything possible was being done to save his life. Fortunately, the time he spent with the cardiologist alleviated his fears.

Will Tech Harm or Help?

Concern over the potential loss of such meaningful patient/physician encounters contributes to Rosenbaum’s questions about the true value of the growing use of data to educate or communicate with patients.

“We have no idea what such digitization means for the patient/physician relationship,” she said. “Consistently absent from ‘meaningful use’ conversations is the recognition that the full-fledged embrace of health IT may not only fall short in achieving its promised outcomes, but may also erode something fundamental to the practice of medicine.”

Rosenbaum explores a range of issues. If, for example, patients get treatment information from care providers and access medical advice through the Internet, who will help them understand the information? Will physicians spend initial visits diligently entering data into a computer, rather than having a conversation with their patients? And ultimately, will health IT lead to better care?

She understands that health IT is here to stay, but suggests that health experts find answers to these questions as they go forward. According to new research from the Palo Alto Medical Foundation (PAMF), used in Rosenbaum’s Academy essay, IT can help some patients. PAMF, an early adaptor of health IT, reports that it has helped its diabetes and hypertension patients achieve better health outcomes.

Rosenbaum simply asks that as health care providers enter this brave new world they apply “critical investigation, patience, and honesty. With that, I think we could learn to use health IT in a way that frees us to spend more time practicing medicine in the manner of those we admire most.”

Healing While Embracing Change

Rosenbaum expressed doubt that “we will ever come up with a metric for the true value of the physician/patient relationship. But we must avoid a world where the new norm for physicians is achieving high performance metrics and simultaneous low patient satisfaction outcomes. We may have to accept that in some situations, it just may be that it’s not possible to spend less time, less money and provide the same quality of care.”